Our overall goal was to reduce patient harm from hospital acquired pressure ulcers (Stage III, IV and Unstageables) by at least 25% in calendar year 2010 and by another 20% in calendar year 2011, aiming at Zero. Hospital-Acquired Pressure Ulcers (HAPU) can be very devastating to both the patient and to the healthcare system. Additionally, hospitals have been negatively impacted due to increased length of stay, cost of treating the pressure ulcer, liability associated with a hospital acquired pressure ulcer and loss of reimbursement from Medicare and other payors. The Pressure Ulcer Prevention Team used FMEA and PDSA tools to identify failure modes and process improvement opportunities. A literature search and a review of the recommendations of the professional organization, the Wound Ostomy Continence Nurses Society was completed. A proactive approach was designed involving extensive education by wound care, piloted in critical care and deployed house-wide. The improvement initiatives are designed to prevent any stage of pressure ulcer development through a Pressure Ulcer Prevention (PUP) Bundle to use on all patients considered at risk for skin breakdown based on best evidence to date.

TCPS Launches PSO Services

Following approval by the THA board of directors, the Tennessee Center for Patient Safety (TCPS) is preparing to launch new patient safety organization (PSO) services.